THE PROOFS OF THE EXISTENCE OF A PHTHISICAL CONTAGION

The contagiousness of tuberculosis is a subject of peculiar interest to the medical profession of this district, inas-much as it was here that our late colleague, Dr. Wm. Budd, startled the profession by announcing his belief that phthisis would be found to be contagious. The grounds of his belief were as follows:?* (a) Considerations based on the pathology of phthisis, as showing it to consist in the evolution and multiplication within the organism of a specific morbid matter, with a universal tendency to elimination and casting forth of the same, after the type of zymotic diseases generally. (b) Actual instances in which there was evidence to show that phthisis was communicated from one person to another.

grounds of his belief were as follows:?* (a) Considerations based on the pathology of phthisis, as showing it to consist in the evolution and multiplication within the organism of a specific morbid matter, with a universal tendency to elimination and casting forth of the same, after the type of zymotic diseases generally.
(b) Actual instances in which there was evidence to show that phthisis was communicated from one person to another.
(c) The geographical distribution of phthisis in past * Lancet, Vol. II., 1867, pp. 451?550. 2 DR. R. SHINGLETON SMITH and present times, and especially its great fatality now in countries which, when first discovered by Europeans, were known to be entirely free from it.
(d) Its much greater prevalence in low levels and amongst crowded communities, and its entire absence, unless by casual importation, at very high levels,?conditions which are well known to rule in the same directions the spread of zymotic diseases generally, and especially in that group in which, as in phthisis, the morbific matter is cast off in a liquid form.
(e) Its very high rate of prevalence in convents, harems, barracks, penitentiaries, &c., that is to say, under the very social conditions which are known most to favour the propagation of diseases of the zymotic group.
Among the data relating to geographical distribution the following striking facts may be here mentioned:? 1. When the South Sea Islands were first discovered phthisis did not exist there. Since the aborigines have come into intimate contact with Europeans the disease has not only made its appearance among them, but has become so wide-spread as to threaten their extermination.
The contrast between the original entire immunity and the present extreme fatality is very striking, and can only be rationally explained by the importation of a new and specific morbific germ. Try every other supposition and the facts are inexplicable; make this one supposition and they are at once explained. 2. The late Dr. Rush, of Philadelphia, who made very accurate enquiries to determine the point, satisfied himself that when America was first discovered phthisis was unknown among the native American Indians. Now it is very fatal to them. The very significant contrast here exhibited between the past and present history of these ON PHTHISICAL CONTAGION. 3 two races, in respect of phthisis, is seen at once, and at the present time among the negro race in Africa in different parts of the area of that great continent.
It is well known that negroes are peculiarly liable to phthisis. Now everywhere along the African seaboard where the blacks have come into constant and intimate relations with the whites, phthisis causes a large mortality amongst them. In the interior, where intercourse with the whites has been limited to casual contact with a few great travellers or other adventurous visitors, there is reason to believe that phthisis does not exist. Dr. Livingstone and other African travellers have given us the most positive assurances on this point.
The following are the principal conclusions to which I have been led regarding phthisis or tubercle :? 1st.?That tubercle is a true zymotic disease, of specific nature, in the same sense as typhoid fever, scarlet fever, typhus, syphilis, &c.
2nd.?That, like these diseases, tubercle never originates spontaneously, but is perpetuated solely by the law of continuous succession. 3rd.?That the tuberculous matter itself is (or includes) the specific morbific matter of the disease, and constitutes the material by which phthisis is propagated from one person to another, and disseminated through society.
4th.?That the deposits of this matter are therefore of the nature of an eruption, and bear the same relation to the disease phthisis as the "yellow matter" of typhoid fever for instance bears to typhoid fever. 5th.?That by the destruction of this matter on its issue from the body, by means of proper chemicals or otherwise, seconded by good sanitary conditions, there is reason to hope that we may eventually, and possibly at scourge.
In support of Dr. Budd's statement with regard to the geographical distribution of the disease, De Quatrefages in his work on "The Human Species" says:?"In the Sandwich Islands Cook calculated the population at 300,000. In 1861 there were but 67,084. Similar facts are true of most other parts of Polynesia.
" Two naval surgeons have been able to throw light on this melancholy problem. They found that tubercles were invariably found in the bodies submitted to examination. Almost all the Polynesians suffer from an obstinate cough, and in eight cases out of ten tuberculosis follows these bronchial catarrhs. " Now phthisis does not appear in the list of diseases drawn up by the old voyagers. Have we then imported it into these islands ? Developing in a new region, in a race to whom it was formerly unkown, this disease assumed a more terrible form." The researches of later times have given much support to a view which has long existed in a smouldering unstable condition.
The most recent discovery, that of Professor Koch, of a definite distinguishing bacillus of characteristic form and size, found in tubercular matter in the body and in tuberculous excreta, capable of being inoculated, capable also of purification by successive growths by a process of artificial cultivation, these facts have given new life to an idea which appeared to be almost dead, have given an impetus to the doctrine of contagium vivum which is not likely to be short lived.
Even as long ago as the times of Galen consumption was supposed to be contagious, and antiseptic treatment of a primitive kind was first attempted when Galen ON  It is only about twenty years ago that Buhl began to teach, apparently as a new idea, that acute tuberculosis is of an infective nature, the disseminated grey granulations being supposed to be the result of absorption of some poisonous material from a caseous focus originating in some inflammatory or scrofulous action. Experimental Evidence. Villemin, in 1865, demonstrated the possibility of inoculating animals with tuberculosis. He found the disease could be readily induced in dogs and rabbits by the inoculation of little bits of tubercle inserted under the skin. Hypodermic injection of small quantities of the sputa of consumptive patients gave the same result.
Villemin's* experiments showed conclusively the possibility of inoculating tubercle from men to the lower animals, and from one animal to another. These results were fully corroborated by Simon,t who found that both the yellow and the grey tubercle are inoculable from man to the rabbit, and from rabbit to rabbit. He concluded that whether it be called tubercle or not the action must be allowed to be specific. A commission of inquiry appointed by the Pathological Society of London to report on Simon's specimens " thought the tuberculous nature of the specimens was beyond reasonable doubt." So also a The researches of Villemin and Cohnheim established the fact that true tubercle may always be inoculated, and this became established as the test by which true and false tubercle might be differentiated. The capacity of a morbid product, when introduced into the body of a rabbit or a guinea pig, to produce tuberculosis in the animal demonstrates the nature of that morbid product : what produces tuberculosis is tubercle, what fails to produce tuberculosis is no tubercle.
The following paragraph, written in May, 1880,* is quite prophetic of recent discoveries :?" Those who are convinced that all contagious virus is due to a parasite will, of course, not hesitate to believe that the tubercular poison is corpuscular, and that, in a not very distant future, this corpuscle will be demonstrated in the tuberclenodule and in scrofulous products. Until, however, this goal is reached there remains no other test for tubercle than that of infection." The writer of this paragraph scarcely suspected that in two years afterwards the examination of sputum in order to establish the diagnosis of phthisis by ocular inspection of the Bacillus tuberculosus would be an every-day occurrence in the wards.
Then came the experiments of Lebert, Burdon-Sanderson, Andrew Clark, Wilson Fox and others, who at first appeared to establish the fact that what was called tuberculosis in animals might be produced by the inoculation, not of true tubercle only, but of any of the products of inflammatory action, or even of putrid substances or by foreign bodies such as a seton. Doubts were thus thrown on the nature of tubercle itself, and it appeared to be * Brit. Med. Jour., p. 704. ON PHTHISICAL CONTAGION. 7 difficult to say what might be true and what pseudo tubercle?the barrier between inflammatory action and a specific tuberculosis appeared to be giving way, and so it got to be assumed that most of the changes going on in the lungs in phthisis were of an inflammatory nature, and that the role of the specific substance, the grey granulation, was far more limited than had been supposed. The  These secondary tubercles, after inoculation with tuberculous matter, had the distinguishing characteristic of increasing infectiousness from successive inoculations. Hence he concludes tubercle is an infective malady, owing to the presence of some morbific agent, peculiar to it, but undetermined.
The most remarkable inoculation experiment on record, and one which has not attracted so much attention * Lancet, Aug. 5 Demet, Paraskeve, and Zallonis, in Syra, Greece, were not only successful in transmitting the disease to rabbits by inoculation with the sputa and blood from a man affected with phthisis, but they ventured on the experiment of inoculating a human patient whose history gave no indications of tuberculous taint, and whose lungs were found to be healthy, but who was suffering from gangrene of the big toe, due to obliteration of the femoral artery. A fatal termination was inevitable, and sputum from a man who had abscesses in his lungs was inoculated in the upper part of thigh. Three weeks afterwards there were evidences of disease at the summit of the right lung, and at the time of death, thirty-eight days from date of inoculation, it was found that the upper lobe of right lung had seventeen tubercles in first stage, two of the size of a lentil, the others as large as a grain of mustard. Two similar tubercles existed at the apex of the left lung. Two tubercular masses were found on the convex surface of the liver."* Numerous other observations show that injection of tuberculous matter from man, from the ox, or from the milk of tuberculous cows will give rise to tuberculosis in pigs, sheep and goats, rarely a positive result in rabbits, a negative result with dogs and cats. Later Viseur, at Arras, showed that cats were not exempt from tubercle induced by the eating of tuberculous matter. " Klebs found that rabbits and guinea pigs were very susceptible to the influence of milk from tuberculous cows, and he accidentally induced the disease in a dog by feeding it with the milk of a phthisical cow. The vital tenacity * Med. Chi. Review, Oct., 1874.

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of tubercle virus appears to be remarkable, as shown by these inoculation experiments: it preserves its potency through three or four generations. Inoculations will succeed with matter from a subject which has been dead 36 hours, and with sputa which has been dried for 20 days. If thoroughly boiled its vitality is destroyed, and Klebs found that the action of alcohol deprived it of its potency."* " Chauveau, of Lyons, in 1868, administered to three healthy calves about thirty grammes of tuberculous matter from an old phthisical cow: the caseous, puriform, and cretaceous mass was pounded in a mortar and dissolved in water, and then administered from a bottle.
"Fifty-two days afterwards the miserable aspect of the three infected creatures contrasted in the most extraordinary manner with the thriving condition of the noninfected one which had been kept under similar conditions for comparison. The autopsy revealed the most perfect lesions of general tuberculosis, the mesentery and intestines being extremely involved. He concludes :? "1. The experiments prove that bovine animals contract tuberculosis by digestive injection. " It was found by Tappeiner,* and others, that in all cases where real tuberculous matter was used tubercles were found in the lungs, kidneys and other organs, the abundance of the tubercles being generally proportionate to the length of the experiments and the frequency of the inhalations. In those cases where non-tuberculous matter had been sprayed into the air no tubercles were found. Carrying the idea a stage further, M. Giboux caused rabbits to inhale the air expired by consumptive patients, and he found that at the end of about three months the rabbits emaciated and at last died from general tuberculosis, whereas other rabbits which were made to inhale similar air filtered through tow charged with carbolic acid showed no impairment of health, and when killed were found to be free from tubercle.
All these experiments point to the conclusion that there must be some special infecting virus in tubercle, and it is now five years ago that Professor Klebs believed that he had demonstrated a necessity for the existence of a microphyte, monas tuberculosus, to which he presumed the contagiousness of tubercle was due; and thereupon Dr. Schiiller, of Greifswald, and others advised the more active antiseptic treatment of the disease. In spite, however, of the suspicions and speculations of various thinkers, and in spite of the abundant evidence from inoculation, evidence amounting almost to mathematical demonstration, no one had as yet succeeded in detecting by ocular evidence any microphyte which might be looked upon as the specific germ by which the disease * Virchow's Archives, vol. lxxiv., 1878.
ON PHTHISICAL CONTAGION. II might be inoculated and by the dissemination and growth of which it might be supposed to spread. ^Professor Koch, of Berlin, has recently given to the world the most striking corroboration of the truth of the theory which hitherto had not received general acceptance. Koch, having previously demonstrated the existence of the bacillus anthracis as the cause of splenic fever, and of various other bacilli in cases of septicaemia, set himself the task of discovering the specific germ which so many authors believed must exist, although its presence could only be proved by indirect evidence. By special methods of aniline staining Koch was at last able to show that in all true tubercles found in cases of general tuberculosis a peculiar micro-organism could be seen. The bacilli of tubercle were found to be delicate rod-shaped bodies, varying in length from quarter to one half the diameter of a blood corpuscle. They are found in all cases within the giant cells of the grey granulation, and are most numerous in recent and advancing tubercle; they become fewer in proportion as the tubercle gets older, and finally disappear on the healing of the tubercular ulcer. The expectoration also was found to contain multitudes of these bacilli, whilst none could be discovered in the sputa of non-tubercular patients. He also found that the bacillus of tubercle required, in inhabitants of the temperate zone, about the warmth of the animal body for its growth and increase, that in fact the bacilli did not increase in numbers in the sputum whereas the putrefactive bacteria would rapidly increase.
A special dye was discovered by which the bacilli could be isolated from all other substances, and thus readily demonstrated by its colour. The process was afterwards 12 DR. R. SHINGLETON SMITH improved by Ehrlich; and various other methods, more particularly that of Heneage Gibbes, have come into operation. The principle of all these methods is the same, viz., to stain the bacilli of one colour and the ground substance of another, by which contrast the minute germs can be readily seen even without the highest powers of the microscope.
Professor Koch did not stop here; having shown the existence of a definite germ, having described its characteristic appearance and its difference from other bacilli which accompany it; having shown that by staining agents it may be differentiated from other similar bodies, and that it requires a special temperature for its growth and multiplication, he then endeavoured to prove that this visible germ is the germ by which the infection of tubercle is conveyed.
His attempts were crowned with complete success; he was able to cultivate the bacilli artificially through many successive generations; after transference from one soil to another a great number of times the original tubercle matter was at length got rid of, and nothing but the bacilli left behind. He then ascertained that inoculation with these bacilli, isolated from all the original matter with which they were associated, was followed by reproduction of the parasite, and the induction of tuberculosis, as certainly as when the tuberculous matter itself was inoculated. Further he found that filtration of the fluid containing the bacilli through porous clay destroyed its virulence, the fluid which passed through became innocuous, whilst the substance which refused to pass the filter would readily give rise to tuberculosis.
The method of cultivation of the bacilli adopted by Koch is not an unimportant part of his discovery, inasmuch as it enables him to isolate any particular form of growth from others which may be accidentally associated ON PHTHISICAL CONTAGION. 13 with it. The pure cultivation of any particular pathogenic bacterium is effected by adding three to five per cent, of gelatine to the infusion or other substance with which he is experimenting; in this way growth takes place on a solid soil, which can be clarified, and will so allow of constant observation as to what is going on upon or within it.
If any accidental growth occur it only spreads at one point, and fresh material can be inoculated from a pure part without risk of contamination.
The bacilli have been found by Dr. Koch in the following cases:?Eleven cases of miliary tuberculosis, twelve positive, but when the material inoculated did not contain bacilli a negative result was obtained, the animal remaining healthy in spite of inoculation. Experiments were performed with the contents of a scrofulous gland, and with degenerated synovial membrane, neither material containing bacilli; and also with the tubercular lung of a monkey, some parts of which had been dried for two months, and some kept one month in alcohol, and in no instance did tuberculosis follow.
That the disease following inoculation was not due to accidental causes independent of the bacilli was shown by the fact that the artificial disease differed from the spontaneous one: such a plentiful crop as occurs after inoculation never develops spontaneously in so short a time; and again in the natural disease the bronchial glands become enlarged and cheesy and then the lung is affected, whereas in the artificial disease the glands nearest to the seat of inoculation (generally in the abdomen) were first enlarged, and the spleen and liver were specially affected.
In order to prove that the bacilli were the real and only cause of the infection it was necessary to proceed a step farther, and to isolate them from all their surroundings by the process of pure cultivation on a solid substratum of gelatine. The ordinary gelatine would not do for the purpose, inasmuch as it was found that these bacilli require a temperature approaching that of the body for their growth, and at this temperature the gelatine cultivating preparations become fluid. The material which was found to answer the purpose the best is blood serum which has been rendered solid by heat, but which has not been exposed to so high a temperature as to become opaque. It was found that about the tenth day after inoculation of this solid blood serum with any tuberculous ON PHTHISICAL CONTAGION. 15 material small points and scales became evident, which slowly spread, and were seen to consist of tubercle-bacilli.
After about fourteen days some of these bacilli were transferred to fresh blood serum, and this process was repeated several times. Thus the original material was entirely got rid of, and only the bacilli developed from it remained ; and now it was found that inoculation with the pure bacilli produced tuberculosis with the same certainty as did the inoculation of tuberculous material containing living bacilli.
Experiments on the lower animals appear to establish the fact that phthisis, being the result of a specific poison, the tubercle bacillus, must be classed amongst the contagious diseases. What evidence can be adduced from the clinical side in support of this view ?
Clinical Evidence (Animals).?As regards the lower animals it appears to be generally admitted that tuberculosis is contagious. Fleming* states that the disease tuberculosis is common in animals, especially in confinement, and that the bovine species are most affected.
Cruzel says that in one hundred old oxen fattened and slaughtered for food at least one half will have the lungs more or less tuberculous, and further that the disease is communicated by the expired air in low badly ventilated buildings, and that it is rare that the breath of bovine animals affected with phthisis has not a remarkable odour from which the disease may be diagnosed. Viseur, of Arras, in 1868, pointed out the persistence of the malady in certain establishments.
Zundel also found this in Brooklyn, New York, a family cow was found in an advanced state of tuberculosis, and the owner and his wife were evidently rapidly sinking under the same malady.
In another case reported to me, a family cow, supposed to be suffering from the lung plague, was found to be afflicted with tuberculosis instead, and the owner's wife (a consumptive), who had been making free use of the milk warm from the cow, was persuaded to give it up, and underwent an immediate and decided improvement. It is for infants and adults who are somewhat infirm or out of health, or whose surroundings are not of the most salubrious kind, that the danger is greatest; but this embraces such an extended class that the moral interests involved are almost illimitable. The destruction of infancy and wasting of manhood from this cause is unquestionably far greater than has been hitherto realised." t Clinical Evidence (Man).?The facts with regard to contagiousness from man to man are thus given by Petersen, in 1870, who sums up the results of his inquiries and observations in the following propositions :? " 1. That a contagious origin of some cases of phthisis cannot on sufficient grounds be denied. 3. That it must justly be considered hazardous to lie in the non-disinfected bed of a phthisical patient, and to be habitually in too close contact with such a person. " 4. That this danger in Denmark seems to be greatest in the warm period of the year."* My own experience on this point is limited to an occasional case in which the husband appears to have taken the disease from the wife, or the wife from the husband. About two years ago I was consulted by a young married man whose wife, much older than himself, had recently died of tubercular phthisis after an illness of about twelve months. His family history was good, father and mother both living, over 60 years of age, and no history of phthisis in his family. His own health had been good till six months after the death of the wife, when he noticed a little cough and expectoration in the mornings with occasional streaks of blood. Haemoptysis in small quantity occurred in October, November, December, 1880, twice in February, 1881, and in March there was a little crepitation at the left supra scapular region. In March, 1882, he had quite recovered: there were no physical signs of disease, but patient was seldom free from cold, and had lost more than a stone in weight. He is now (May, 1883) quite well.
Another case which has come to my notice is that of a husband and wife in a country village reputed to be healthy, who both died within a day of each other of tubercular phthisis, six years after their marriage. The wife, aged 30 at time of death (in August, 1882), was one of five sisters, whose father died of consumption in 1871. She had never been very strong, and at the age of 18 was supposed to be consumptive, at the time when her * Med. Chi. Review, July, 1870. ON PHTHISICAL CONTAGION. 19 father was laid up with lung disease. After her marriage she seems to have been quite well, and stronger than before, with no suspicion of any disease of the lungs.
Three years after their marriage the husband, then aged 26, got a succession of colds, and was never well afterwards.
Two years after the commencement of the husband's illness the wife caught cold, spat blood, and then rapidly failed in every respect. She was in constant attendance on, and cohabited with, her husband during the whole period of his illness. phthisical, and died September, 1880, aged 50, of phthisis.
The mother, during her husband's last illness, complained of cough, and spat blood. She rapidly lost flesh, and died of phthisis in April, 1881. The elder daughter is still a strong, hearty woman." The facts suggest two questions:?1. Did the younger daughter inherit from the father's side a phthisical taint, which developed subsequently in the father himself? 2. Was the mother's a case of phthisis communicated from husband or daughter ? Mr. Bernard Kendall, of Clifton, gives me a history of two cases of apparent contagion:?" C. K., fifth son in a family of thirteen children (of whom eight are now living, the eldest being 60 years of age) married a lady in delicate health, and who was constantly obliged to winter by medical advice at Torquay, or other places in the South of England. They lived together for about six years, when the wife died of phthisis, and the husband, who was supposed to have contracted his disease from her, died about two years afterwards from the same disease. One other member of the family died of phthisis, a younger brother, who was in the mercantile service, and who contracted the disease in the China seas." . " M. W. died of phthisis, and was closely attended by his wife, who had previously enjoyed good health. She is supposed to have contracted the disease from her husband, and she died last week of phthisis." Numerous isolated cases of apparent contagion are recorded by various observers, and the enquiries being Leudet % gives an account of fifty-six families, of which in fifteen the husband was tubercular at marriage and the wife then healthy, and in forty-one the wife was alone affected. Of the first fifteen, in five the wives became affected, two having had relatives dying of consumption, and a third not becoming affected till ten years after her husband's death. Of the other series, only three husbands became affected, and of these one had lost a sister from tuberculosis. He concludes as follows :? " i. Wives contract tuberculosis more readily from their husbands than husbands from their wives. " 2. Wives who are not themselves affected may give birth to children who die of phthisis.    23 to the action of the poison of variola, scarlet fever, typhus, &c. We can only account for the escape of the many, by supposing that there are certain conditions of health in the few affected ones, which so degrade the vitality of the tissues as to render them a fit breeding ground for this particular form of bacterium, and that only under these conditions will the parasite germinate and prosper. On the other hand there are certain mechanical difficulties in the way which may also account for the only occasional growth of these organisms in those who appear to be fit subjects. It is probable that the lungs are the more usual mode by which the germs gain access to the body. Now, it has been assumed by Lister, and proved by Prof. Tyndall,* that the air which passes along the respiratory passages becomes purified in its transit, and is absolutely aseptic in the air cells and finer air passages : hence it follows that any particles suspended in it will be arrested by the mucous membrane and the larger tubes, and the bacilli will therefore be unable to reach the deep recesses of the lungs: when so arrested ciliary action will gradually cause them to travel back towards the trachea, and they will ultimately be ejected in the bronchial mucus discharged by coughing. Koch found in his cultivating experiments that, under ordinary conditions simulating those within the body, the bacilli undergo little or no change for about ten days; meanwhile long before germination has taken place they will be too far away from the lungs to effect any mischief. It is true that particles of carbon and other foreign bodies, such as cinnabar, do and may be made by experiment to reach the ultimate recesses of the lungs, but it is probable that this mechanical difficulty in transit may be one of the causes * Tyndall, Floating matter of the air, pp. 36, 37. 24 dr. r. shingleton smith why so many persons escape the action of these widely distributed germs.
If mere debility, a mere want of resistance to outside influences, a mere degradation of vitality of the tissues constituted the reason why one begets the disease and another does not, it would be difficult to account for the only occasional cropping up of phthisis as a direct sequel to various acute diseases more particularly of the lungs.
It is a familiar fact that cases of chronic pleurisy of simple inflammatory origin, although in general aspect simulating phthisis, are yet essentially different in their nature and results; the specific virus is wanting, and the patient slowly gets well after a very protracted illness, which can scarcely be distinguished clinically from some forms of tubercular phthisis. Again it has been a matter of constant remark that " cold " is powerless to excite tubercle. The soldier, exposed to all the inclemencies of a campaign, sees phthisis disappear from the ranks, while in the comfort and warmth of garrison life he finds his comrades decimated by its ravages. The sailor, again, threatened with tubercular lung disease, finds that the open air life at sea, with exposure to all weathers and in all latitudes, soon restores the failing health and removes the disease which may have already commenced. The germ theory of tuberculosis also accounts for the fact that tubercle loves lowlying places, and is not met with at certain altitudes : just as Professor Tyndall could safely open some of his hermetically sealed tubes with organic infusions at the top of some of the alpine peaks without risk of introducing germs from the pure air around, so the pure air of these altitudes is little likely to give rise to a purely zymotic disease. Again, the warmth of the tropics is likely to be favourable to the growth of the bacilli, which accounts for ON PHTHISICAL CONTAGION. 25 the rarity of the disease at the poles, the increase of intensity towards the tropics, and its exceeding malignancy there. Tubercle, again, finds its habitat in crowded places, and is intense in direct proportion to the concentration of the population, as in prisons, barracks, factories, &c. In illustration of this point may be mentioned the fact that phthisis was found to be three times more prevalent in Millbank than in London generally, and the prisons of France and Algeria were found to show similar results. Mere crowding in all parts of the world on the other hand, and re-breathing the same air as in the snow huts of the Greenlander, has not been shown to give rise to phthisis.
The absence of a frequent occurrence of direct contagion will scarcely be considered a powerful argument against the formidable array of facts in favour of the contagiousness of phthisis. It is highly probable that a more careful observation of the conditions surrounding the onset of the disease will show that a possible direct contagion is more frequent than is generally supposed, or has yet been shown to be. Every one will remember the long debated question as to the contagiousness of typhoid: no one now doubts the existence of a definite typhoid poison to which alone when introduced to the body under certain favourable conditions the disease is due : we cannot always trace the mode of entrance, but we admit that the poison must have been introduced. Just as the typhoid poison is discharged by one particular excretion, so in phthisis the poison may be given off by one excretion only, and this not in a form which is likely to gain access to the bodies of others whilst the germs are still active.
There is however one way in which self-infection from one Part of the body to another is very easy, and it having been shown that tuberculosis in animals is easily induced by artificial feeding with tuberculous matter, is it not probable that the intestinal lesions of chronic phthisis are the result of self-infection by the swallowing of the secretions from the lungs ?
Mr. T. F. Edgeworth reports to me a case of chronic diarrhoea, with disease in the lungs, which is clearly of a tuberculous nature; the patient never expectorates anything, but on extracting the mucus from the throat after a cough the product is found to contain numerous bacilli, and the faecal evacuation also contains bacilli, with the characters of those found in tuberculous sputum.
Dr. Davey, of Clifton, informs me that insane patients rarely expectorate, but he was not able to form an opinion as to whether intestinal ulceration is more frequent in cases of phthisis found in the asylums for the insane than in those found elsewhere. On my mentioning this topic to Dr. A. Law Wade, of the Wells Asylum, he examined the recent records, and found that since July, 1882, there had been 14 deaths from phthisis, and in six of these there were tubercular ulcers in the intestines ; in two the lining membrane of colon was thickened and congested throughout; in two there were patches of deep congestion, which did not appear to have proceeded to actual ulceration of surface, both of these were of short duration, one was a case of acute tuberculosis, and the other of phthisis with acute pneumonia. Some confirmatory evidence as to the contagiousness of phthisis has been adduced by Mr for it either by constitution or by preceding disease, or by reduced surroundings, and even when it has picked out a feeble member of the flock and attacked such an organ as the lung, is usually impotent against those portions whose functional activity is greatest, and is prone to affect those in which renewal of air and removal of exfoliated epithelium are least perfectly performed, such as parts which have been inflamed or tied down by previous thickening of the pleura, and especially the comparatively unused apices of the lungs. When we see the chest of a phthisical patient covered with patches of cloasma, the thickened and unremoved epithelium infiltrated by the spores and mycelium of the microsporon furfur, we may carry the mind's eye inwards and think of the apices of the lungs and the similar processes going on within them, their air cells, little moved by the feeble respiratory efforts of the patient, gradually plugging up with exfoliated epithelium, matted together by the growth of tubercular bacilli, which, although carried in far greater number into those portions of the lung whose functional activity is greater, have only been able to take root in the half-dead epithelium of the stagnant apicial air-cells." Additional evidence in favour of, and in demonstration of the existence of a contagion in phthisis, has been adduced in the investigation of the question as to the diagnostic and prognostic value of the bacillus tuberculosis * Practitioner, April, 1883. + Lancet, August 26th, 1882. in the sputum and elsewhere. Various observers have worked energetically in this direction, and the most important results are the following:? Balmer and Frsentzel* have given an account of 120 cases of phthisis in which the sputa were examined. The bacilli were found in all. They believe that the number and degree of development of these are of considerable prognostic value, that the more rapid the process of lung destruction the larger is their number, it being greatest towards the end of the disease. They found that in the rapid cases the organisms were not only numerous but large, well developed, and spore-bearing, but on the other hand, when the disease was arrested or making very slow progress, they were small, presented no trace of spores, and were always few in number.
They sum up their conclusions thus :? " 1. A definite prognosis may be made from the number and stage of development of the bacilli in sputa. " 2. The number of bacilli in sputum increases proportionately with the advance of the destructive process in the lung, and attains its maximum as the end approaches. " 3. Distribution of bacilli is not in all cases the same. Sometimes they are evenly scattered and sometimes are in groups. " 4. Their appearance is not constant. They are often small, ill developed, and without spores, and small in number. " 5. Such bacilli are found when the disease is progressing but slowly or has been checked. "  7. In every case in which the bacilli were plentiful there was high fever, and the converse was also true. " 8. The difference in quantity of bacilli in the fluid of a cavity and that in the lung tissue surrounding the excavation was very marked, numerous in the former, scanty in the latter. " 9.
From this it appears that the sputum affords a more favourable place of growth than does the still living lung tissue. " 10. We may not ascribe the rich development of bacilli in the lung cavity to the presence of oxygen, for they are equally abundant in the purulent secretion of a tuberculous joint."* Dr. Whipham gives results of examination of 20 cases, and was disposed to think that in acute tuberculosis and in exacerbations of the disease the bacilli were especially numerous in the sputa, and that when the disease is arrested, or the patients improving, the organisms were greatly reduced in number or disappeared from the expectoration.t In the discussion which followed the reading of the above mentioned paper at the Medical Society of London, Dr. Samuel West gave his own observations and the following deductions:? " 1. He had found bacilli present in every case of phthisis which he had examined, though in some cases they were in such small numbers as only to be found after repeated and very careful examination. " 2. The number he had found, as a general rule, to vary with the rate of breaking down of the lung, and therefore, in most cases, with the gravity of the disease. 31 " 3. The arrangement of the bacilli in the sputum varied much. At times they were isolated, few in number or many, and very numerous in rapid cases; at other times arranged in groups or masses, and this appeared to be the rule in the most rapid cases. " 4. In some instances the bacilli contained small, bright bodies, which had been called spores, and this seemed to be a common condition in acute cases. " 5. There appeared to be but little variations in the size of the individual bacilli in different cases. " 6. In cavities the bacilli existed in large numbers, and usually in masses. The more cheesy matter, or fluid from a cavity, there was in the expectoration the more bacilli we might expect to find ; consequently, in a case of acute tuberculosis, before breaking down of the lung, we should expect to find none." Dr. Burney Yeo pointed out that the absence of bacilli was as important diagnostically as their presence, and mentioned cases in illustration of this fact.
Dr. C. T. Williams gave results of examination of sputum in 130 cases at the Brompton Hospital. Twentyone were cases other than phthisis, in no one of these did the sputum contain bacilli. The 109 others were cases of phthisis in its various forms, and in 106 of these the bacilli were found, whilst in the three others it could not be affirmed with certainty that they were absent.
Dr. Heneage Gibbes pointed out the existence of two forms of miliary tubercle. In the reticular form he had only succeeded in finding bacilli in three cases, and these in small numbers distributed throughout the reticulum. In the non-reticular form, the tubercles having no fibrillation, and no ant cells, but consisting of irregular cells in the periphery and a caseous mass in the centre, he had 32 DR. R. SHINGLETON SMITH invariably found bacilli in large numbers in the caseous centre.
He also pointed out the existence of bacilli even in the smallest tubercles. Again, a lung may be stuffed with tubercle, each one containing thousands of bacilli, and yet the patient will die before the destructive process has gone far enough to cause any of them to be ejected in the sputum.* D'Espine, of Geneva, believes the bacillus to be of the greatest diagnostic value, but worthless as an element in estimating the prognosis. His conclusions are based on the examination of twenty cases with a positive result, and five cases of emphysena and bronchitis with a negative result.t Dr. Heron gives the results of examination of sputum in sixty-two cases, all of which presented the usual symptoms which we associate with phthisis, and in all of which the bacilli were observed. He ventures to think that the prognosis of cases of consumption will, for the future, hinge upon the numbers and forms in which the bacilli are found in the sputum.
He believes that the most rapidly fatal are those in which the bacilli are seen to be grouped in numerous masses throughout the sputum. J An interesting and important observation, showing the diffusion of bacilli in the air inhaled by patients with tuberculous disease, has been made by Dr. Arthur Ransome.
In 1869 the author had examined the aqueous vapour of breath in health and disease. Vapour was condensed in a glass globe, surrounded by ice and salt, and in condensing it was found to carry down all suspended organic matters. On examining the breath of several advanced cases of phthisis, specimens of bacillus were * Lancet, Feb. 24th, p. 321. + Ibid, Jan. 13th, 1883. X Ibid, Feb. 2nd, 1883. 33 found in two cases, in several other cases the organism Was not found, and it was not found in the aqueous vapour condensed in the waiting-room of the Manchester Consumption Hospital. In order to carry down the organic matter and to afford a basis to attach the material to the cover-glasses, fresh white of eggs, or a little mucus, was added to the fluid. The cover-glasses were treated by Dr. Heneage Gibbes's method of staining.* This observation is supported by Dr. R. Charnley Smith, who allows the patient to breathe through gun cotton, which is afterwards converted into collodion, and examined for bacilli after the usual process of staining.t Since my own observations began I have not once failed to detect the tuberculous bacilli in cases which, from other evidence, were assumed to be undoubted ones of tubercular phthisis. On several occasions I have failed to find them on the first examination, and during the cold Weather of early winter I obtained only imperfect and unsatisfactory evidence in two or three cases of advanced phthisis at about the same time. One of these (No. 21) soon died, and was shown to be one of rapid tuberculosis by post mortem examination; the purulent nummular sputum was repeatedly examined, and only very few illdefined and ill-stained organisms could be seen, scarcely sufficiently marked to establish their identity. The same result was found in another case at the same time; No. 20 was a case of chronic phthisis, with old cavities, and here I was not able to satisfy myself with the evidence of their presence. My partial failure on those two occasions Was no doubt due to the fact rightly pointed out by Dr.
adopted the method of warming the staining fluid for the purpose of securing more perfect and more rapid staining, I have been able to obtain the sputum from case No. 20, and found that the bacilli, although not numerous, are very readily and satisfactorily demonstrated. In a third case, No. 19, I did not at first find bacilli, probably from the same cause (the low temperature of the air), and as the case was one of constitutional syphilis in which lung symptoms had recently manifested themselves, it was of some importance to make subsequent examinations : when this was done, a few weeks later, the bacilli were found to exist in large numbers. These cases convinced me that no amount of length of exposure of the sputum to the action of the staining fluid would compensate for too low a temperature : the glasses were frequently allowed to remain for twelve and twenty-four hours floating on the stain, and still no bacilli were visible; whereas, if the fluid were treated with a spirit lamp till it began to give off steam, the staining would be rapid and the bacilli would be easily demonstrated.
The whole number of cases I have examined and recorded is 77: of these 49 were one or other of the various forms of tubercular phthisis: the remaining 28 had various other affections of the lung, some of them closely simulating phthisis : the list includes chronic bronchitis, bronchiectasis, chronic syphilitic pneumonia, slight haemoptysis with no evidence of any disease, chronic pleuro-pneumonia, chronic pleurisy, apex pneumonia with subsequent breaking down from gangrene, sarcoma of lung, grey hepatisation, congestion from mitral disease, diabetes with bronchitis; two cases with strong family history of phthisis, cough with purulent expectoration, but with no evidence of local disease in lungs, the patients rapidly recovering.
Of the whole series of cases there are some few of special interest.
Case 8 was admitted in consequence of sloughing of both tonsils. There was also abundant disease in the lungs. Bacilli were found in the sputum, as well as in the mucus dug out from the cripts of the disintegrating mass of the tonsil.
By carbolic spray and antiseptic inhalations the throat gradually got well, and the general health improved. The question arises were the tonsils infected by the passage over them of the mucus containing the bacilli ? and this question also suggests another, whether laryngeal disease may not be also a result of local infection from the same cause ?
Case 7 was admitted in consequence of chronic diarrhoea, but with little evidence of disease in the lungs. This soon followed, and death took place in six weeks from the first onset of lung symptoms. Post mortem examination was not allowed, but the case appears to be a good illustration of acute pulmonary phthisis arising by infection from a previously diseased intestine.
Case 30 was admitted with symptoms of chronic bronchitis, and no evidences of phthisis were obtained at the first examination.
The sputum was found to contain abundant bacilli, and then a more careful examination disclosed the presence of dulness at the right upper lobe.
Death took place in two months, the lung having broken down rapidly, and it was found to be riddled with cavities from apex to base. The mucus obtained from the cavities on the post mortem table was found to contain densely crowded masses of bacilli.
Case 39 was one of chronic cystitis of four years dura- Of the series of cases in which no bacilli were found:?
Case 2 was one of chronic syphilitic disease of lungs, with evidences of cavity in the upper part of left lower lobe. A few months before, a drainage tube had been passed into this cavity through the chest wall, and the subsequent progress of the patient had been very satisfactory.
He again recently came under observation with bronchitis and much muco-purulent sputum, but no bacilli could be detected, and the patient rapidly improved under treatment with iodide of potassium and iodoform. A series of cases of special interest are the following: The three patients belong to a family of thirteen, with a slight phthisical history. One sister died from acute phthisis, a brother died from acute pneumonia, and a second from some lung disease. Case No. 5 is that of the brother, 30 years of age, who was laid up in January, 1882, with acute pleurisy; he was then said to have pleuropneumonia, and afterwards acute phthisis. When I saw him in May, 1882, he had evidence of chronic pleuropneumonia of the right side, with a suspicion of cavity at the upper part of lower lobe. There was no evidence of disease at either apex. The nails were clubbed, and he was anaemic, but had no temperature, and only complained of dyspnoea on exertion. There had been abundant expectoration of muco-pus, which had commenced suddenly in February, and had continued more or less freely.
In December, 1882, he again came under observation, now with some slight hepatic enlargement, and a trace of albumen in urine. Through the winter he expectorated, at times very freely, but I was never able to find any tuberculous bacilli.
In April he left Clifton much improved in general condition, having gained weight, having no expectoration, with no albumen in urine, no enlarge" nient of liver, and with no evidence of anything more than chronic pleuro-pneumonia of right lung. The absence of tuberculous bacilli from the sputum quite supports the evidence derived from physical signs, that the disease is and has been a simple inflammatory one, and that its tendency is to cause waxy degeneration of the viscera from chronic suppuration rather than the usual results of pulmonary phthisis. This patient's sister, case No. 6, is of a similar character.
She is 26 years of age, has had chronic pleurisy of left side for two years, is well nourished, but anaemic, and complains of dyspnoea on exertion. There is no decided dulness on percussion, the breath sounds are feeble, crepitation can be heard all down the left side both in front and behind. There is a little non-purulent expectoration, containing putrefactive but no tuberculous bacilli. The physical signs are now at least suggestive of chronic phthisis, but the whole history of the case is that of chronic pleurisy.
The third case of the series, No. 32, is another sister, 24  There was a decided hectic flush, and shehad copious night sweating. Expectoration was free,, consisting of muco-pus, which was found to be crowded with tuberculous bacilli.
Another sister in the same family was said to be dying of phthisis ten years ago, but is now living and in good health, with no evidence of any lung weakness.
We have here in the same family two sisters and a brother, all with chronic lung disease, two of them of an inflammatory, the other of a typical tuberculous character,, the sputum of the latter crowded with bacilli, whilst that of the two former contains none. The phthisical sister and the non-phthisical brother are now living in the same house, and the bacilli are no doubt disseminated freely throughout the house in spite of antiseptic inhalations and1 disinfection of sputum. The brother, debilitated by chronic pleurisy and chronic suppuration in lung, affords in all probability an excellent field for the growth of bacilli. It will not be surprising if in spite of all precautions his purulent sputum becomes a nidus for thegrowth of the tuberculous germs, should he escape the perils associated with waxy disease which now threaten him.
May not this be the reason why so many cases of chronic pleurisy ultimately die of phthisis, that they become fit subjects for the growth of these all-prevalent tuberculous germs ?

39
Lichtheim had previously observed them in the pelvis of the kidney of a patient who had died from the same disease.
Burney Yeo also states that they have been observed by Barrow in the urine. One of my cases (No. 39) is another illustration of their occurrence in the urine in chronic cystitis, which at last culminated in acute miliary tuberculosis of the lungs, the bacilli being present in the urine and in the sputum. The discharges from the intestine of this patient were not examined for bacilli, but in all probability they would have been found if sought for. They have previously been observed by Lichtheim in the stools of tuberculous patients.* As regards the examination of faeces, Dr. H. Menchet holds that the presence of the true tubercle bacillus in the intestinal contents is due to the admixture of the secretions of tuberculous ulcers, and that the bacilli are found only in the stools of the really tuberculous. It has been asserted that similar bacilli in the faeces stain in the same way, and are undistinguishable therefore from the bacilli of tubercle. I have myself examined the stools of only two or three cases, in one of these I found numerous tuberculous bacilli, case No. 48 ; this was a case of chronic diarrhoea, with phthisis, in which the sputum contained bacilli. In another patient, with chronic diarrhoea from carcinoma of liver, I found numerous putrefactive bacteria, but no bacilli which would be recognised as like those of tubercle. Further observations are necessary to establish the value of the presence of tubercle bacilli in the faeces as an aid to diagnosis, and, as pointed out by Lichtheim, single staining is better than double staining for this purpose, as in this way the other micro-organisms remain invisible.
The Cases are epitomised in two classes: the one in which Tuberculous Bacilli were found, the other in which they were believed to be absent.
CASES IN WHICH TUBERCULOUS BACILLI WERE FOUND:? 4^ 10 No.